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Walker RC, Palmer SC, Abel S, Jones M, Walker C, Tipene-Leach D. Health care delivery of kidney transplantation to indigenous Māori in Aotearoa New Zealand: A qualitative interview study with clinician stakeholders. J Health Serv Res Policy 2024; 29:257-265. [PMID: 38662788 DOI: 10.1177/13558196241248525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/27/2024]
Abstract
OBJECTIVES Indigenous people experience higher rates of kidney failure than do non-Indigenous Peoples. However, compared to Indigenous patients, health care systems deliver kidney transplantation to non-Indigenous patients at a substantially higher rate and more frequently as the first treatment of kidney failure. Indigenous Māori patients in Aotearoa New Zealand report numerous barriers to kidney transplantation. We explore the perspectives of clinicians as stakeholders in the delivery of kidney transplantation. METHODS In 2021/2022 we conducted in-depth qualitative interviews with key stakeholder clinicians within kidney transplantation services in Aotearoa New Zealand, asking them about the issues for Māori patients. We used thematic analysis informed by critical theory to identify key findings and used structural coding to categorize the themes at the level of society, health system, and health services. RESULTS We interviewed 18 clinicians (nine nephrologists, including two transplant nephrologists, and nine nurses, including six transplant coordinators). We identified nine themes from stakeholders related to delivery of kidney transplantation services to Māori patients and whānau (family), categorized according to three main levels: Firstly, at the level of society (the impact of colonization and distrust). Secondly, the health care system (failure to prevent and manage kidney disease, health care model delivers inequitable outcomes, and inadequate Māori health professional workforce). Thirdly, health care services (transplantation reliant on patient and family resources, complex assessment causes untimely delays, clinical criteria for transplantation, and lack of clinician ability to effect change). CONCLUSIONS Delivery of kidney transplantation to Indigenous Peoples is impacted at the level of society, health care system, and health care service. To address inequities, a broad approach that addresses each of these levels is required.
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Affiliation(s)
- Rachael C Walker
- School of Nursing, University of Auckland, Auckland, New Zealand
| | - Suetonia C Palmer
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Sally Abel
- Independent Health Researcher, Napier, New Zealand
| | - Merryn Jones
- Transplant Nurse, Renal Services, Te Whatu Ora - Te Matau a Māui, Christchurch, New Zealand
| | - Curtis Walker
- Department of Medicine, Te Whatu Ora - Te Pae Hauora o Ruahine o Tararua, Palmerston North, New Zealand
| | - David Tipene-Leach
- Te Kura i Awarua Rangahau Māori Research Centre, Te Pukenga - Eastern Institute of Technology, Napier, New Zealand
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Arunachalam V, Lea R, Hoy W, Lee S, Mott S, Savige J, Mathews JD, McMorran BJ, Nagaraj SH. Novel genetic markers for chronic kidney disease in a geographically isolated population of Indigenous Australians: Individual and multiple phenotype genome-wide association study. Genome Med 2024; 16:29. [PMID: 38347632 PMCID: PMC10860247 DOI: 10.1186/s13073-024-01299-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 01/30/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is highly prevalent among Indigenous Australians, especially those in remote regions. The Tiwi population has been isolated from mainland Australia for millennia and exhibits unique genetic characteristics that distinguish them from other Indigenous and non-Indigenous populations. Notably, the rate of end-stage renal disease is up to 20 times greater in this population compared to non-Indigenous populations. Despite the identification of numerous genetic loci associated with kidney disease through GWAS, the Indigenous population such as Tiwi remains severely underrepresented and the increased prevalence of CKD in this population may be due to unique disease-causing alleles/genes. METHODS We used albumin-to-creatinine ratio (ACR) and estimated glomerular filtration rate (eGFR) to estimate the prevalence of kidney disease in the Tiwi population (N = 492) in comparison to the UK Biobank (UKBB) (N = 134,724) database. We then performed an exploratory factor analysis to identify correlations among 10 CKD-related phenotypes and identify new multi-phenotype factors. We subsequently conducted a genome-wide association study (GWAS) on all single and multiple phenotype factors using mixed linear regression models, adjusted for age, sex, population stratification, and genetic relatedness between individuals. RESULTS Based on ACR, 20.3% of the population was at severely increased risk of CKD progression and showed elevated levels of ACR compared to the UKBB population independent of HbA1c. A GWAS of ACR revealed novel association loci in the genes MEG3 (chr14:100812018:T:A), RAB36 (rs11704318), and TIAM2 (rs9689640). Additionally, multiple phenotypes GWAS of ACR, eGFR, urine albumin, and serum creatinine identified a novel variant that mapped to the gene MEIS2 (chr15:37218869:A:G). Most of the identified variants were found to be either absent or rare in the UKBB population. CONCLUSIONS Our study highlights the Tiwi population's predisposition towards elevated ACR, and the collection of novel genetic variants associated with kidney function. These associations may prove valuable in the early diagnosis and treatment of renal disease in this underrepresented population. Additionally, further research is needed to comprehensively validate the functions of the identified variants/genes.
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Affiliation(s)
- Vignesh Arunachalam
- Centre for Genomics and Personalised Health and School of Biomedical Sciences, Queensland University of Technology, Brisbane, QLD, Australia
| | - Rodney Lea
- Centre for Genomics and Personalised Health and School of Biomedical Sciences, Queensland University of Technology, Brisbane, QLD, Australia
| | - Wendy Hoy
- Centre of chronic disease, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Simon Lee
- Centre for Genomics and Personalised Health and School of Biomedical Sciences, Queensland University of Technology, Brisbane, QLD, Australia
| | - Susan Mott
- Centre of chronic disease, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Judith Savige
- Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC, Australia
| | - John D Mathews
- Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Brendan J McMorran
- National Centre for Indigenous Genomics, The John Curtin of Medical Research, Australian National University, Canberra, ACT, Australia
| | - Shivashankar H Nagaraj
- Centre for Genomics and Personalised Health and School of Biomedical Sciences, Queensland University of Technology, Brisbane, QLD, Australia.
- Translational Research Institute, Queensland University of Technology, Brisbane, QLD, Australia.
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Ball J, Zhang J, Stanley J, Waa A, Crengle S, Edwards R. Addressing Intergenerational Inequity in Tobacco-Harm: What Helps Children of Smokers to Remain Nonsmokers? Nicotine Tob Res 2024; 26:102-110. [PMID: 37586082 PMCID: PMC10734381 DOI: 10.1093/ntr/ntad148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/27/2023] [Accepted: 08/14/2023] [Indexed: 08/18/2023]
Abstract
INTRODUCTION Children of people who smoke are more likely to take up smoking themselves. In Aotearoa New Zealand (NZ), adolescent smoking declined dramatically between 2000 and 2016 despite limited change in parental smoking, demonstrating that the cycle can be broken. AIMS AND METHODS This study aimed to identify modifiable factors associated with never smoking in Year 10 students (14-15 years) who had at least one caregiver who smoked. We used data from the Youth Insights Survey (2016 and 2018, pooled, N = 5,422) and identified students with at least one caregiver (mother, father, grandparent, other caregiver) who smoked (N = 2,205). To investigate modifiable factors potentially associated with nonsmoking we used logistic regression with marginally adjusted prevalence estimates. RESULTS Overall, 41% of students had at least one caregiver who smoked. In this group, the majority (65%) had never smoked themselves. After adjustment, never-smoking was more prevalent among students attending low-deprivation (more affluent) schools (73% had never smoked) compared to high-deprivation schools (44%); students not exposed to others' smoking inside the home (72%) or in cars (70%) in the past week compared to those exposed (59% and 51%, respectively); and students whose parents would be upset if they were caught smoking (68% vs 49% for those whose parents would not be upset), or who had high self-esteem (69% vs 55% for those with low self-esteem). CONCLUSIONS Modifiable factors independently associated with non-smoking in adolescents with caregiver(s) who smoked were: nonexposure to smoking inside the home and in cars, parental expectations of nonsmoking, and high self-esteem. IMPLICATIONS Even in countries like NZ with relatively low adult smoking rates, children's exposure to caregiver smoking may be prevalent, particularly in structurally disadvantaged populations. This study suggests that action to promote smokefree homes and cars, build high self-esteem in young people, and communicate expectations of non-smoking are likely to help children of people who smoke to remain nonsmokers. A comprehensive approach that also addresses "upstream" factors (eg, socioeconomic deprivation) and underlying causes of structural inequity (eg, institutional racism) is needed. Such policy and community action may help to break intergenerational cycles of tobacco use and health inequity.
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Affiliation(s)
- Jude Ball
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Jane Zhang
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - James Stanley
- Dean’s Department, University of Otago, Wellington, New Zealand
| | - Andrew Waa
- Eru Pōmare Māori Health Research Centre, University of Otago, Wellington, New Zealand
| | - Sue Crengle
- Ngāi Tahu Māori Health Research Unit, University of Otago, Dunedin, New Zealand
| | - Richard Edwards
- Department of Public Health, University of Otago, Wellington, New Zealand
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Gomes OV, de Souza CDF, Nicacio JM, do Carmo RF, Pereira VC, Barral-Netto M, da Costa Armstrong A. Epidemiology of chronic kidney disease in older indigenous peoples of Brazil: findings from a cross-sectional survey. Aging Clin Exp Res 2023; 35:2201-2209. [PMID: 37517045 DOI: 10.1007/s40520-023-02510-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 07/16/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND Chronic kidney disease (CKD) is a prevalent disease worldwide, with increasing incidence particularly in low- and middle-income countries. Indigenous communities have poorer CKD outcomes due to limited access to healthcare. They are also experiencing a shift toward a sedentary lifestyle and urbanization-related dietary changes, increasing the risk of CKD-related risk factors. AIM To determine the prevalence of CKD in older Brazilian indigenous and identify the main associated risk factors. METHODS This cross-sectional study analyzed demographic and clinical data of 229 older indigenous individuals aged 60 years and above in 2022-2023. CKD was defined as an estimated glomerular filtration rate < 60 mL/min/1.73 m2 or a urinary albumin-creatinine ratio > 30 mg/g. Data were presented categorically and analyzed using the Chi-square test or Fisher's exact test. RESULTS The prevalence of CKD in the population was 26.6%, with higher prevalence in women and increasing with age. The prevalence of hypertension and diabetes was 67.7% and 24.0%, respectively, and these comorbidities were associated with CKD: hypertension (OR = 5.12; 95% CI 2.2-11.9) and diabetes (OR = 5.5; 95% CI 3.7-8.2). No association was found between the prevalence of CKD and obesity, dyslipidemia, cardiovascular disease, or smoking. DISCUSSION The study found a higher prevalence of CKD among older indigenous populations in Brazil compared to non-indigenous populations, which is exacerbated by risk factors, such as aging, hypertension, diabetes, and lifestyle changes, emphasizing the importance of early detection and intervention in these communities. CONCLUSION Older persons' indigenous individuals have a high prevalence of CKD, which is correlated with factors, such as sex, age, diabetes mellitus, and hypertension.
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Affiliation(s)
- Orlando Vieira Gomes
- Postgraduate Program in Human Ecology and Socio-Environmental Management, Bahia State University-UNEB, Juazeiro, Bahia, Brazil.
- Faculty of Medicine, Federal University of Vale do São Francisco-UNIVASF, Petrolina, Pernambuco, Brazil.
| | - Carlos Dornels Freire de Souza
- Postgraduate Program in Human Ecology and Socio-Environmental Management, Bahia State University-UNEB, Juazeiro, Bahia, Brazil
- Faculty of Medicine, Federal University of Vale do São Francisco-UNIVASF, Petrolina, Pernambuco, Brazil
| | - Jandir Mendonça Nicacio
- Postgraduate Program in Human Ecology and Socio-Environmental Management, Bahia State University-UNEB, Juazeiro, Bahia, Brazil
- Faculty of Medicine, Federal University of Vale do São Francisco-UNIVASF, Petrolina, Pernambuco, Brazil
| | - Rodrigo Feliciano do Carmo
- College of Pharmaceutical Sciences, Federal University of Vale do São Francisco-UNIVASF, Petrolina, Pernambuco, Brazil
| | - Vanessa Cardoso Pereira
- Postgraduate Program in Human Ecology and Socio-Environmental Management, Bahia State University-UNEB, Juazeiro, Bahia, Brazil
| | - Manoel Barral-Netto
- Oswaldo Cruz Foundation/Fiocruz, Institute Gonçalo Moniz, Salvador, Bahia, Brazil
| | - Anderson da Costa Armstrong
- Postgraduate Program in Human Ecology and Socio-Environmental Management, Bahia State University-UNEB, Juazeiro, Bahia, Brazil
- Faculty of Medicine, Federal University of Vale do São Francisco-UNIVASF, Petrolina, Pernambuco, Brazil
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Gomes OV, Guimarães MP, Nicacio JM, Morena L, Silva AMLD, Morais Junior JCD, Souza CDFD, Barral Netto M, Lima JAC, Armstrong ADC. Urbanization and kidney dysfunction in Brazilian indigenous people: a burden for the youth. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2023; 69:240-245. [PMID: 36888763 PMCID: PMC9983479 DOI: 10.1590/1806-9282.20220934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 11/14/2022] [Indexed: 03/08/2023]
Abstract
OBJECTIVE The aim of this study was to investigate whether the degree of urbanization influences the prevalence of chronic kidney disease in Brazilian indigenous people. METHODS This is a cross-sectional study conducted between 2016 and 2017 in northeastern Brazil and includes individuals aged between 30 and 70 years from two specific indigenous groups who volunteered to participate in the study: the Fulni-ô people (lowest degree of urbanization) and the Truká group (greater degree of urbanization). Cultural and geographical parameters were used to characterize and measure the magnitude of urbanization. We excluded individuals with known cardiovascular disease or renal failure who required hemodialysis. Chronic kidney disease was defined as a single measurement of an estimated glomerular filtration rate <60 mL/min/1.73 m2 using the Chronic Kidney Disease Epidemiology Collaboration creatinine equation. RESULTS A total of 184 indigenous people from the Fulni-ô group and 96 from the Truká group with a median age of 46 years (interquartile range: 15.2) were included. We found a chronic kidney disease rate of 4.3% in the total indigenous population, generally affecting an older population: 41.7% over 60 years old (p<0.001). The Truká people had a chronic kidney disease prevalence of 6.2%, with no differences in kidney dysfunction across age groups. The Fulni-ô participants had a chronic kidney disease prevalence of 3.3%, with a higher proportion of kidney dysfunction in older participants (of the six Fulni-ô indigenous people with chronic kidney disease, five were older). CONCLUSION Our results suggest that a higher degree of urbanization seems to negatively influence the prevalence of chronic kidney disease in Brazilian indigenous people.
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Affiliation(s)
- Orlando Vieira Gomes
- Universidade do Estado da Bahia, Postgraduation Program in Human Ecology and Socio-Environmental Management - Juazeiro (BA), Brazil.,Universidade Federal do Vale do São Francisco, School of Medicine - Petrolina (PE), Brazil
| | | | - Jandir Mendonça Nicacio
- Universidade do Estado da Bahia, Postgraduation Program in Human Ecology and Socio-Environmental Management - Juazeiro (BA), Brazil.,Universidade Federal do Vale do São Francisco, School of Medicine - Petrolina (PE), Brazil
| | - Leela Morena
- Universidade Federal do Vale do São Francisco, School of Medicine - Petrolina (PE), Brazil
| | | | | | | | | | | | - Anderson da Costa Armstrong
- Universidade do Estado da Bahia, Postgraduation Program in Human Ecology and Socio-Environmental Management - Juazeiro (BA), Brazil.,Universidade Federal do Vale do São Francisco, School of Medicine - Petrolina (PE), Brazil
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A Study on CKD Progression and Health Disparities Using System Dynamics Modeling. Healthcare (Basel) 2022; 10:healthcare10091628. [PMID: 36141240 PMCID: PMC9498548 DOI: 10.3390/healthcare10091628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/17/2022] [Accepted: 08/23/2022] [Indexed: 11/17/2022] Open
Abstract
Chronic kidney disease (CKD) is one of the most prevalent national health problems in the United States. According to the Center for Disease Control and Prevention (CDC), as of 2019, 37 million of the US’s adult population have been estimated to have CKD. In this respect, health disparities are major national concerns regarding the treatments for patients with CKD nationwide. The disparities observed in the healthcare interventions for patients with this disease usually indicate some significant healthcare gaps in the national public health system. However, there is a need for immediate intervention to improve the present healthcare conditions of minorities experiencing CKD nationwide. In this research, the application of system dynamics modeling is proposed to model the CKD progression and health disparities. This process is based on the health interventions administered to minorities experiencing CKD. The graphical results from the model show that there are relationships among the dynamic factors influencing the incidence and prevalence of CKD. Hence, healthcare disparities are inherent challenges in the treatment and management of this disease.
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Harasemiw O, Komenda P, Tangri N. Addressing Inequities in Kidney Care for Indigenous People in Canada. J Am Soc Nephrol 2022; 33:1474-1476. [PMID: 35667707 PMCID: PMC9342645 DOI: 10.1681/asn.2022020215] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Oksana Harasemiw
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada.,Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Paul Komenda
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada.,Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Navdeep Tangri
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada .,Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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Wong G, Lim WH, Hughes JT. Breaking Down the Silence: Call for Action to Address Access Disparities to Transplantation in Indigenous Māori Peoples With Kidney Failure. AMERICAN JOURNAL OF KIDNEY DISEASES 2022; 80:4-6. [DOI: 10.1053/j.ajkd.2022.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 02/24/2022] [Indexed: 11/11/2022]
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Eneanya ND, Boulware LE, Tsai J, Bruce MA, Ford CL, Harris C, Morales LS, Ryan MJ, Reese PP, Thorpe RJ, Morse M, Walker V, Arogundade FA, Lopes AA, Norris KC. Health inequities and the inappropriate use of race in nephrology. Nat Rev Nephrol 2022; 18:84-94. [PMID: 34750551 PMCID: PMC8574929 DOI: 10.1038/s41581-021-00501-8] [Citation(s) in RCA: 62] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2021] [Indexed: 12/13/2022]
Abstract
Chronic kidney disease is an important clinical condition beset with racial and ethnic disparities that are associated with social inequities. Many medical schools and health centres across the USA have raised concerns about the use of race - a socio-political construct that mediates the effect of structural racism - as a fixed, measurable biological variable in the assessment of kidney disease. We discuss the role of race and racism in medicine and outline many of the concerns that have been raised by the medical and social justice communities regarding the use of race in estimated glomerular filtration rate equations, including its relationship with structural racism and racial inequities. Although race can be used to identify populations who experience racism and subsequent differential treatment, ignoring the biological and social heterogeneity within any racial group and inferring innate individual-level attributes is methodologically flawed. Therefore, although more accurate measures for estimating kidney function are under investigation, we support the use of biomarkers for determining estimated glomerular filtration rate without adjustments for race. Clinicians have a duty to recognize and elucidate the nuances of racism and its effects on health and disease. Otherwise, we risk perpetuating historical racist concepts in medicine that exacerbate health inequities and impact marginalized patient populations.
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Affiliation(s)
- Nwamaka D Eneanya
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - L Ebony Boulware
- Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Jennifer Tsai
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Marino A Bruce
- Program for Research on Faith, Justice, and Health, Department of Behavioral and Social Sciences, University of Houston College of Medicine, Houston, TX, USA
| | - Chandra L Ford
- Center for the Study of Racism, Social Justice & Health, Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Christina Harris
- VA Greater Los Angeles Healthcare System, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Leo S Morales
- Division of General Internal Medicine, University of Washington, Seattle, WA, USA
| | - Michael J Ryan
- Division of General Internal Medicine, University of Washington, Seattle, WA, USA
| | - Peter P Reese
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Roland J Thorpe
- Program for Research on Men's Health, Hopkins Center for Health Disparities Solutions, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Michelle Morse
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Valencia Walker
- Department of Paediatrics, Ohio State University College of Medicine, Columbus, OH, USA
| | | | - Antonio A Lopes
- Clinical Epidemiology and Evidence-Based Medicine Unit of the Edgard Santos University Hospital and Department of Internal Medicine, Federal University of Bahia, Salvador, Brazil
| | - Keith C Norris
- VA Greater Los Angeles Healthcare System, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
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